Christian Scheurlen

Phase II study of photodynamic therapy and metal stent as palliative treatment for nonresectable hilar cholangiocarcinoma.

BACKGROUND The combination of photodynamic therapy and biliary drainage by plastic endoprosthesis insertion has produced promising results in the treatment of nonresectable hilar cholangiocarcinoma. The feasibility and efficacy of intraductal photodynamic therapy with subsequent biliary drainage by self-expandable metal stent insertion were evaluated in a prospective phase II study. METHODS Twenty-four patients were treated with photodynamic therapy after sensitization with porfimer sodium. A plastic endoprosthesis was inserted immediately thereafter and replaced by a metal stent 4 weeks later. A retrospectively analyzed group of 20 patients treated only with biliary drainage served as a historical control group. RESULTS In 19 of the 24 patients, insertion of a metal stent was technically feasible. The 30-day and 60-day mortality rates were 0%. A significant decrease in serum bilirubin was noted in all patients and quality of life remained stable throughout follow-up. Mean and median survival were, respectively, 15.9(3.1) and 9.9: 95% CI [6.4, 13.4] months after photodynamic therapy. In the control group, mean and median survival were, respectively, 12.5(3.4) and 5.6: 95% CI [3.7, 7.6] months, which was not statistically significantly different from the photodynamic therapy group. CONCLUSIONS Photodynamic therapy with consecutive biliary drainage by insertion of a self-expandable metal stent is feasible. With respect to the small benefit in overall survival, randomized controlled trials are warranted.

Cholestasis associated with mesalazine therapy in a patient with Crohn's disease

BACKGROUND/AIMS Mesalazine is a widely prescribed medication, developed as an alternative to sulfasalazine in the treatment of inflammatory bowel disease. In contrast to sulfasalazine, there are only a few case reports on its causing hepatic injury. We here report on a patient with cholestasis after mesalazine therapy for Crohns disease of the ileum. METHODS/RESULTS The patient, a 30-year-old man, developed clinical signs of severe hepatic injury 4 months after treatment with mesalazine (4 g/day) including biopsy-proven hepatocellular cholestasis with minimal focal mononuclear inflammatory infiltration. Contrary to previous reports, no symptoms of generalized hypersensitivity were seen. The patients illness was resolved by discontinuing the mesalazine treatment and he recovered completely in 40 days. CONCLUSIONS This case reinforces the possibility of a causal relationship between mesalazine treatment and toxic hepatic injury without systemic hypersensitivity.

Endoscopic manometry of esophageal varices: evaluation of a balloon technique compared with direct portal pressure measurement

BACKGROUND/AIMS Recently, a non-invasive endoscopic balloon technique for esophageal manometry was published. In the present study, we assess its methodological aspects together with the relationship to portal pressure. METHODS In 20 patients with liver cirrhosis who had received an intrahepatic portosystemic stent-shunt (TIPS), we evaluated portal and variceal pressure before and after balloon occlusion of TIPS (random order). Portal pressure was measured continuously via a portal venous catheter, and variceal pressure was determined at the same time independently by two endoscopists using two balloon techniques (inflation until varix collapses; deflation until varix reappears). RESULTS Overall, mean (+/-SD) portal pressure (28.5+/-7 mmHg) was significantly higher (p<0.001) than mean variceal pressure (24.4+/-6 mmHg). Balloon manometry-determined variceal pressure values were 10+/-15% higher with the inflation technique (26.2+/-7 mmHg) than with the balloon deflation technique (22.6+/-6 mmHg, p<0.001). Portal pressure and variceal pressure correlated significantly (p<0.001; balloon inflation: r=0.61, balloon deflation: r=0.66, mean values of inflation and deflation: r=0.68). Short-term TIPS occlusion led to mean increases of 52% and 35% in portal pressure and variceal pressure, respectively. The manometry results of both endoscopists correlated well with either balloon technique (r> or =0.93; p<0.001) and we saw no adverse effects. CONCLUSIONS Variceal balloon manometry provides non-invasive variceal pressure data which correlate to portal pressure assessed prior to and after short-term TIPS occlusion. However, probably due to variance in collateral anatomy, variceal pressure does not exactly predict portal pressure and its acute changes in the individual patient. The averaged variceal pressure of the inflation and deflation balloon technique provides the best relation to portal pressure combined with a good interobserver reliability and warrants further clinical evaluation.